ED nurses must stop these triage mistakes that could get them sued

Suits against ED nurses may increase due to crowded waiting rooms

A triage nurse tells the ED physician that two young boys have high fevers and rashes, but fails to mention one crucial fact: that two ticks were removed from one of the boys. As a result, the boy was misdiagnosed with measles when he actually had Rocky Mountain spotted fever, and he died as a result. The ED nurse was held liable for negligent conduct.1

In another case, a triage nurse failed to tell a man with flu-like symptoms to stop taking over-the-counter acetaminophen, although hydrocodone-acetaminophen was prescribed. The man was sent to X-ray for an outpatient ultrasound, but hours later, he came back to the ED with an altered level of consciousness.

"By the time he arrived back in the ED, his glucose was 21, and he was obviously jaundiced with fulminate hepatic liver failure from an accidental [acetaminophen] overdose," says Kathryn Eberhart, BSN, RN, CEN, a Santa Rosa, CA-based legal nurse consultant and ED nurse at Santa Rosa Memorial Hospital. "He subsequently died a few days later from the liver failure."

If a complete triage assessment had been done, the liver failure probably would have been recognized earlier and the man might not have died, says Eberhart. The case settled for an undisclosed amount.

Mary Ann Shea, JD, RN, a St. Louis-based legal nurse consultant, says, "Lawsuits alleging negligent triage arise when the nurse fails to identify and act upon an emergency condition in a timely manner. This can even happen to a well-informed triage nurse who fails to perform the assessment steps necessary to recognize the emergent nature of the patient's condition."

Overcrowding and long wait times are increasing liability risks for ED nurses, according to Shea. "Nurses might feel pressured to triage faster and fail to complete an adequate examination," she says.

Shea says she would not be surprised to see lawsuits against triage nurses increase. "More patients are being pushed through at a faster pace than some nurses can safely handle," she says.

At Carondelet St. Mary's Hospital, a number of interventions were done to improve safety in triage. "We struggle with the same problem as most EDs, with long waits to be seen," reports Diana Platt Lopez, RN, BSN, clinical educator for emergency services. Nurse satisfaction also was an issue, she says. "Who wants to work in triage, if all the patients are upset because of the waits?"

Reassessment of patients waiting to be seen is a major challenge, notes Lopez. "The issue is that the 55 beds you have in the ED are your patients, but so are the other 50 out in the waiting room waiting to get inside," she says. You need to reassess those persons and upgrade them if their condition deteriorates, Lopez warns. "That is a real challenge when your staff is already busy and your triage staff are busy seeing the new 'in-comers' who haven't been looked at yet," she says.

To reduce liability risks, do the following:

Don't give patients false reassurance.

When frantic parents told a triage nurse that their infant had turned blue at home and seemed very sick, they demanded to see a physician immediately. To calm them, the triage nurse reassured them that the baby would be fine and told them to wait. The parents left the ED, and the child died later that night.

Because the triage nurse failed to take a complete history and didn't bring the baby to the physician's immediate attention, the hospital was ordered to pay almost $2 million for negligence.2

"A comprehensive triage needs to be completed, including documentation of that comprehensive triage," says Eberhart. Document the time of contact with the patient, a triage assessment, the conversation that took place, and the specific words you told the patient such as "please don't leave" or "the child needs to be seen," says Eberhart.

Under the Emergency Medical Treatment and Labor Act (EMTALA), any patient who comes to the ED requesting care or treatment needs a medical screening examination performed by a qualified medical person, which in many cases is the emergency department physician on duty, stresses Sue Dill, RN, MSN, JD, director of hospital risk management for Columbus, OH-based OHIC Insurance Co. False assurance never should be provided, she adds. "Nurses do not diagnose. Physicians do. Setting accurate and realistic expectations is important."

• Provide frequent inservices.

ED nurses at Carondelet complete an annual self-learning packet on triage protocols that addresses changes to triage such as medication reconciliation or how to manage behavioral health patients when the ED is full.

"We fortunately have not had any mistakes related to under triage for a long time," says Lopez. "All of our staff who are new to ED nursing get a full day of didactic lecture on triage and spend time training with the triage nurses after they have been here about six months."

• Use dedicated triage nurses.

At Carondelet's ED, throughput time was slower when dedicated triage nurses weren't used, because some nurses were unfamiliar with protocols. "Also, dedicated triage nurses were the ones who suggested and developed all of our triage protocols in conjunction with our ED physicians," says Lopez. For example, nurses order X-rays at triage based on assessment findings using the Ottawa Ankle Rule criteria. (See protocol used by the ED's triage nurses.)

• Add nurses to triage as volume increases.

During peak volumes at Carondelet's ED, Mobile Assistance Team (MAT) nurses assist with procedures and triage. "Our MAT nurses are our more experienced nurses who can see 'the big picture' of what is going on and where they are most needed as helping hands," says Lopez.

The policy is, if the triage nurse has more than six charts in the rack waiting to be triaged, they contact the MAT nurses or charge nurse for help until they catch up. "We have up to three MAT nurses in the department at any given time, based on volume," says Lopez. (See job description of the ED's MAT.)

• Flag charts with "priority" labels.

Laminated pink-colored sheets labeled "Priority" are used at Carondelet's ED, with a blank space for nurses to write the last time assessed. "They also serve as covers to protect [protected health information]. In case anyone is walking by, they can't see any patient information on the chart in the rack," says Lopez.

• Do sufficient charting.

If a nurse walks by the chart rack to place a patient in a room, they should be able to look at the triage assessment and know what the patient's complaint is and whether that patient needs a specific room for treatment or has any special needs, says Eberhart.

"There is usually too brief of a note that really doesn't tell the reader much," she says. "Many triage nurses do not fill out the history section or don't pull the history out of the patient."

Eberhart points to a recent case in which the triage nurse documented a history of "liver disease" and "many meds." The patient's husband alleged that nurses never asked how severe the liver disease was. The woman subsequently died due to hemorrhage, and a lawsuit was filed. "The patient had been worked up weeks earlier for a possible liver transplant," she recalls. The verdict was for the defense, but if the patient had been triaged appropriately, it's likely the patient would have survived and the case never would have been filed, Eberhart adds.

"Patients don't understand how a separate disease process can affect their injury. It's a nurse's responsibility to elicit the history and dig for those answers to the best of their ability," she says.

• Don't ignore "gut feelings."

Sometimes it's just a "sixth-sense" feeling that a patient is really sick, says Eberhart. She gives the example of an elderly cancer patient who complained of not feeling well after a fall. "I reached over and felt for a pulse, which was weak and thready," she recalls. Eberhart immediately hooked her up to a cardiac monitor. The patient was in ventricular tachycardia, Eberhart says.

"I could have spent much longer in triage trying to discern what was wrong with her," Eberhart says. "It really was a gut feeling and nothing I can absolutely put my finger on."


  1. Ramsey v. Physicians Memorial Hospital, 36 Md. App. 42, 373 A.2d 26 (1977).
  2. South Fulton Medical Center, Inc. v. Poe, 480 S.E. 2d 40 (Ga. App., 1996).


For more information on reducing liability risks related to triage, contact:

  • Sue Dill, RN, MSN, JD, Director of Hospital Risk Management, OHIC Insurance Co., 155 E. Broad St., Fourth Floor, Columbus, OH 43215. Telephone: (614) 255-7163. Fax: (614) 242-9806. E-mail: sue.dill@ohic.com.
  • Kathryn Eberhart, BSN, RN, CEN, Eberhart Medical Legal Consulting, 4706 Devonshire Place, Santa Rosa, CA 95405. Telephone: (707) 538-7056. E-mail: ebers@sonic.net.
  • Diana Platt Lopez, RN, BSN, Clinical Educator, Emergency Services, Carondelet St Mary's Hospital, 1601 W. St. Mary's Road, Tucson, AZ 85745. Telephone: (520) 740-6193. E-mail: dplopez@carondelet.org.
  • Mary Ann Shea, JD, RN, Attorney at Law/Registered Nurse, P.O. Box 220013, St. Louis, MO 63122. Telephone: (314) 822-8220. Fax: (314) 966-0722. E-mail: masheajdrn@aol.com.